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General NPI Number Information
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NPI Number | 1144762337
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Entity Type | Organization
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Legal Business Name | FATHERHOOD REVISITED
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Dates
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Enumeration Date | 11/06/2016
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Last Update Date | 03/14/2022
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Provider Practice Location Address
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Address Line | 10925 REED HARTMAN HWY STE 310C
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City | BLUE ASH
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State | OH
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Zip | 45242-2842
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Country | US
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Telephone | 513-549-4172
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Fax | 513-586-0452
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Provider Business Mailing Address
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Address Line | PO BOX 12685
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City | CINCINNATI
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State | OH
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Zip | 45212-0685
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Country | US
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Telephone | 513-549-4172
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Fax |
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Authorized Official
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Title or Position | CEO/FOUNDER
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Name | MS. KEISHA RENEE PETTIJOHN
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Credential |
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Telephone | 513-549-4172
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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